title: Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience.
abstract: BACKGROUND
  Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31% to 50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury.
  
  
  METHODS
  A retrospective review of all patients presenting to a single Level I trauma center who required pancreaticoduodenectomy for trauma from 1996 to 2010 was performed. We collected demographic and in-hospital data and compared subjects based on their initial operation.
  
  
  RESULTS
  Fifteen patients (median age, 29 years; 93% male; median Injury Severity Score [ISS], 35) underwent pancreaticoduodenectomy following blunt (n = 5) or penetrating trauma (n = 10). Twelve patients (80%) underwent damage-control surgery (DCS) with or without the initial stage of Whipple resection as their first operation. Three patients (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic, and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy versus DCS (460 [98] minutes vs. 243 [112] minutes). There were no overall differences in complication rates, although the two patients who did not experience a complication had DCS. In-hospital mortality was 13% (n = 2).
  
  
  CONCLUSIONS
  We present both the largest series of patients to date who underwent a DCS or staged Whipple procedure for complex pancreaticoduodenal trauma and the largest series with blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature, less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia, and coagulopathy in patients with severe pancreaticoduodenal trauma as well as the proven benefits of DCS, we propose that these patients should undergo initial DCS and staged reconstruction.
authors.affiliation: University of Washington/Harborview Medical Center, Seattle, Washington 98104, USA. lliemt@uw.edu
authors.forename: Callie M
authors.initials: CM
authors.lastname: Thompson
authors.forename: Sherene
authors.initials: S
authors.lastname: Shalhub
authors.forename: Zachary M
authors.initials: ZM
authors.lastname: DeBoard
authors.forename: Ronald V
authors.initials: RV
authors.lastname: Maier
mesh_terms: D000293:Adolescent; D000328:Adult; D004386:Duodenum / Q000293:injuries* / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000293:injuries* / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000379:methods / Q000401:mortality; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000601:surgery; D014950:Wounds, Penetrating / Q000601:surgery; D055815:Young Adult